Oncology Clinical Impact of Residual Extraretroperitoneal Masses in Patients With Advanced Nonseminomatous Germ Cell Testicular Cancer Timothy A. Masterson, Bobby Shayegan, Brett S. Carver, Dean F. Bajorin, Darren R. Feldman, Robert J. Motzer, George J. Bosl, and Joel Sheinfeld OBJECTIVE Integration of platinum-based chemotherapy and surgical resection of residual masses is essential in the management of advanced nonseminomatous germ cell tumors (NSGCT). We reviewed our institutional experience in patients undergoing resection of extraretroperitoneal (ERP) residual masses after chemotherapy to assess its impact on cancer progression and survival. METHODS Between 1989 and 2003, 532 patients with advanced NSGCT underwent postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) with a median follow-up of 41 months. Survival probabilities were estimated by the Kaplan–Meier method. Cox proportional hazards regression analysis was used to determine the prognostic significance of risk factors for progression and survival. RESULTS Of 532 patients, 402 (76%) underwent PC-RPLND alone, and 130 (24%) underwent resection of ERP residual disease concurrently or in a staged fashion within 6 weeks. Concordance between retroperitoneal (RP) and ERP sites of disease was 83% in the presence of fibrosis, 42% for teratoma, and 47% for viable NSGCT. Overall, 34% of patients undergoing resection of ERP residual disease had either teratoma or viable disease on final pathology. Five-year probability of freedom from progression was 74% (95% CI 65%, 82%) and disease-specific survival was 84% (95% CI 75%, 89%). On multivariable analysis the histologic findings at the ERP site were significant predictors of disease progression, independent of the RP findings. CONCLUSION Our data suggest that teratoma or viable NSGCT is present in approximately one-third of patients undergoing resection of residual ERP disease. The presence of residual ERP teratoma and viable NSGCT predicts for cancer progression independent of RP histology. UROLOGY 79: 156 –159, 2012. © 2012 Elsevier Inc. T esticular cancer is the most common cancer in men aged 20-35 years and accounts for approx- imately 1% of all male malignancies. 1 Approx- imately 30-40% of men with nonseminomatous germ cell tumors (NSGCT) have evidence of metastatic disease at the time of initial presentation. 2 Through a multimodal approach to the management of advanced NSGCT incorporating induction chemotherapy fol- lowed by postchemotherapy resection of residual dis- ease, cure rates now exceed 80%. 3,4 However, despite advances with platinum-based regimens, up to 35% of patients will have radiographic evidence of extraretro- peritoneal (ERP) disease after chemotherapy. 5 Because of the varied discordance rates between retroperitoneal (RP) and ERP pathologies ranging from 29-46% 6-8 and limitations in predicting histology, surgical resection of any residual mass identified on postchemotherapy imaging is recommended at our institution. Although outcomes for patients undergoing postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) for residual disease within the RP have been well documented, little is known about the impact residual teratoma or viable germ cell tumor (GCT) within an ERP site has on progression and survival rates. The purpose of our study was to characterize the clin- icopathologic features of patients with advanced NSGCT undergoing surgical resection of ERP residual masses after chemotherapy, and to assess the clinical impact of ERP sites of disease on cancer progression and survival. From the Department of Surgery, Urology Service, Memorial Sloan-Kettering Cancer Center, New York, NY; Department of Urology, Indiana University, Medical Center, Indianapolis, IN; and Department of Medicine, Genitourinary Oncology Service, Memorial Sloan-Kettering Cancer Center, New York, NY Reprint requests: Joel Sheinfeld, M.D., Sidney Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan-Kettering Cancer Center, 353 East 68th Street, New York, NY 10021. E-mail: sheinfej@mskcc.org Submitted: August 9, 2011, accepted (with revisions): September 28, 2011 156 © 2012 Elsevier Inc. 0090-4295/12/$36.00 All Rights Reserved doi:10.1016/j.urology.2011.09.038